The form on this page can be used to submit an online Coverage Determination (prior authorization or exception) request if you want us to consider coverage of a Part D prescription medication.
Please note that fields marked with an * are required fields.
For urgent requests, you may also call 1-844-786-6762 (TTY/TDD: 711), 24 hours a day, 7 days a week to initiate the process.
Please read through the following information carefully. It is very important that the Request for Coverage Determination be filled out completely and accurately. If you have any questions please contact Member Services at the number listed on your ID card.
Who May Make a Request: Your prescriber may ask us for a coverage determination on your behalf. If you want another individual (such as a family member of friend) to make a request for you, that individual must be your representative. Contact us to learn how to name a representative.